Provider Demographics
NPI:1144646498
Name:LIEBERMAN, DEREK
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:LIEBERMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:544 N LEWIS AVE
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-3536
Mailing Address - Country:US
Mailing Address - Phone:631-245-2514
Mailing Address - Fax:
Practice Address - Street 1:877 STEWART AVE
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-4803
Practice Address - Country:US
Practice Address - Phone:516-745-0202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-11
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY01749363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant